Wednesday, December 10, 2008

Federal employees should take note. Your enrollment deadline for health benefits may have been extended this year, and you should pay special attention to the options available to you. The following excerpt is taken directly from www.federaldaily.com:

"In response to widespread concerns over benefit changes that would have required many Federal Employees Health Benefits Program (FEHBP) subscribers to pay a new $7,500 co-payment for out-of-network non-emergency surgeries, the Office of Personnel Management has asked FEHBP carriers to reevaluate those benefits—and has instructed federal agencies to accept belated enrollments for the 2009 open season. The new co-payment in question would have affected enrollees in the FEHBP Blue Cross/Blue Shield (BC/BS) Standard Option. OPM told insurance carriers to propose changes no later than Dec. 8. OPM also said it would not allow changes to premiums or to other types of benefits in 2009. The extension and request for changes comes in the wake of a Dec. 3 hearing on the matter by the House Subcommittee on the Federal Workforce. At that hearing, Dr. Peter Petrucci, president of the medical staff at Sibley Memorial Hospital in Washington, D.C., noted that the new BC/BS policy would make it “financially prohibitive for the majority of patients to obtain surgery and many commonly performed procedures from the doctor of their choice,” and instead force them to obtain those services from providers who had contractual agreements with insurers. BlueCross/Blue Shield insures more than half of federal employees and retirees. To see more, go to: www.opm.gov/news/opm-to-provide-additional-protections-in-2009-for-fehb-enrollees-who-use-outofnetwork-surgeons,1443.aspx."

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Wednesday, December 3, 2008

In an OWCP claim, it really all comes down to medical reports. Medical reports explain how your medical problem was caused by your job. And medical reports document, on an ongoing basis, how your injury or condition continues to limit your ability to work. Accurate, thorough and timely medical reports are the cornerstone of a successful OWCP claim.

That is why OWCP’s unfair and one-sided handling of medical reporting is so egregious. Here’s how it works:

Once your claim is approved, OWCP requires periodic medical reports from your doctor. These reports are to be written in the form of a narrative, discussing how you were hurt, what has transpired from then until now, and how your condition or need for treatment relates to that injury. This can be a complicated and time-consuming report for your doctor to prepare. But, here's just one of the many places that OWCP plays “gotcha.” Their letter will tell you that your doctor should bill them for this medical report, but they don’t provide explicit billing instructions. If you ask for clarification, they will tell you that the doctors' offices are supposed to know how to bill for what they do. (Guess what, they often don’t know how to bill OWCP.)

The billing code for this sort of a medical report is 99455 (for your treating doctor) and 99456 (if it is any other doctor). But, be advised that this code can only be used once a year on a case, and the doctor cannot bill for units of time, just the code. Your doctor will then get paid a set amount that is far below what OWCP pays their selected second-opinion and referee examiners. And what happens if you have two doctors--an orthopedic surgeon and a psychiatrist? What happens when your claims examiner asks for another report or wants to ask follow up questions from your doctor? What happens if you have a new or additional doctor who needs to spend a significant amount of time reviewing your records in order to prepare a report? According to OWCP, that's your problem; they are not going to pay for this.

Whereas your doctor will only get paid for one report per year, OWCP will frequently send you to multiple doctors and get multiple “clarification reports” in any one year. You better believe their doctors are paid for each and every report, and they are paid the going rate for their services.

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About Me:

I am an attorney who represents injured federal employees with their OWCP cases. I have over two decades of experience in this area. I have clients all over the U.S. as well as overseas. My constant (sometimes frustrating) dealings with the OWCP have been the inspiration behind this blog.